DR. TODD JAROTSKI D.M.D., M.SC.

DR. MICHAEL LAM D.M.D., M.SC.

PATIENT INFORMATION:

Patient First Name:

Patient Last Name:

Birth date:

Pronouns:

Age:

Address:

City/Town:

Postal Code:

Whom may we thank for referring you to our office?

CONTACT INFORMATION:

Patient Cell Phone:

Home Phone:

Patient Email:

How do you wish to be reminded of your appointments (check off all that apply)?

Other:

IF PATIENT IS A MINOR:

Parent/Guardian First/Last Name:

Cell Phone Number:

Work Number:

Email:

Parent/Guardian First/Last Name:

Cell Phone Number:

Work Number:

Email:

Please list any other family members that were/are patients at our office.

MEDICAL HISTORY:

Physician:

Last medical check-up:

Present health status:

Past severe illnesses?

Yes No

Past hospitalization?

Yes No

Past facial trauma?

Yes No

Current medications?

Yes No

Allergies (medications, latex, nickel, etc)?

Yes No

If yes to any of the above, please explain:

DENTAL HISTORY:

What are the patient's concerns regarding the teeth and jaw?

Dentist:

Last dental check-up:

How often do you go for dental check-ups?

Have the following ever been present?

Thumb or finger sucking Tooth grinding/clenching Speech problem Other jaw problems

If yes to any of the above, please explain:

FINANCIAL RESPONSIBILITY:

Person financially responsible for the orthodontic treatment of:

Name:

Phone:

Address:

Postal Code:

Do you have a dental plan covering orthodontic treatment?

Yes No

Signature of financially responsible party (Required even if you have insurance or additional coverage)

Signature

INSURANCE INFORMATION:

Do you have a dental plan covering orthodontic treatment?

Yes No

Name of Insurance Company/Companies:

Group / Policy #:

Certificate / ID #:

Subscriber Name:

(Please ask if you require assistance with your insurance information)

Do you have a second dental plan covering orthodontic treatment?

Yes No

Name of Insurance Company/Companies (2nd plan):

Group / Policy # (2nd):

Certificate / ID # (2nd):

Subscriber Name (2nd):

We do not direct bill insurance companies but would like your insurance information on file.

ADDITIONAL COVERAGE:

Do you have supplementary coverage through Family Health Benefits?

Yes No

Health services #:

Do you have coverage through First Canadian Health (NIHB)?

Yes No

Client identification #:

ACKNOWLEDGEMENT AND CONSENT:

I acknowledge Saskatoon Orthodontics' Privacy Policy and consent to collection, use and disclosure of my personal information for the following services:

Name:

To provide me with orthodontic services To obtain payment of my account Communications/follow up regarding my care Uses described in Privacy Policy

Other (describe):

Restricted Access - My personal information shall NOT be provided to:

Restricted Information - Personal information disclosed shall NOT include:

Signature / Signature of parent if a minor (print name):

Signature

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